JMIR Publications

ABSTRACT

Background:

The increasing population of senior citizens has led to a rise in the demand for healthcare services, with chronic diseases being a major burden. Person-centered integrated care is required to address these challenges; hence, the Turkish Ministry of Health has initiated strategies to implement an integrated healthcare model for chronic disease management.

Objective:

We aim to present the design, implementation, and initial nationwide performance results of the national Disease Management Platform (DMP). The objective of this platform is to enable the implementation of an integrated health service model for chronic disease management in Turkey in a family physician-centered manner. It aims to ensure that national clinical treatment protocols that are designed based on evidence-based clinical guidelines are carried out effectively and easily followed with the help of decision support services.

Methods:

Disease Management Platform is an integrated care solution that heavily utilizes clinical decision support systems to coordinate effective screening and management of chronic diseases in adherence to evidence based clinical guidelines and hence to increase quality of health care delivery. The DMP is designed to enable screening and risk assessment for healthy citizens, disease progression monitoring for already diagnosed patients, and population tracking. It proposes personalized goals and preventive treatment recommendations based on national care pathways, offers personalized care plans, updates them during regular follow-up encounters, and recommends referral to specialists based on patients’ needs.

Results:

The DMP has been used by 23,617 health professionals to perform 49,006,906 encounters for 12,287,655 unique citizens. It has been used to screen and monitor chronic diseases such as hypertension, obesity, diabetes, and cardiovascular risk, resulting in the diagnosis of more than 2.6 million obesity, 384,077 high cardiovascular risk, 359,006 diabetes, and 113,288 hypertension patients.

Conclusions:

The system is designed to be interoperable with existing health IT solutions via HL7 FHIR, and it maximizes the effect of evidence-based decision support services by seamless integration with point-of-care EHRs, lack of which has been listed as one of the main deficiencies of existing solutions. As the system is built upon HL7 FHIR, international code systems and CDS Hooks standard, adaptation and deployment to additional regional and national settings becomes easily possible. It has been demonstrated that the platform can scale horizontally, and efficiently provides services to thousands of FMPs. The system is designed in a modular way, and through the repeatable, well-defined co-creation methodology, it can be easily extended for additional diseases.